APPLICATION FORM FOR AN ADDITIONAL LICENCE

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1 A. NATURAL PERSONS APPLICATION FORM FOR AN ADDITIONAL LICENCE I. IDENTIFICATION Company number:... Name:... First name(s):... National registry number:... Address: Street:... No:... Box: Postal code:... Municipality:... Country:... Telephone:... address:... Commercial name of the website:... II. JUDICIAL PAST Pursuant to the legal provisions, the Gaming Commission will verify whether you fulfil the moral requirements in the Central Judicial Record, whether you are registered in the municipal register and whether you possess full political and civil rights. III. FINANCIAL SITUATION 1) Income Please provide an overview of your income during the past three years by means of a copy of your two most recent tax declarations (+ Annex 2 if you already are self-employed). For the period not covered by the tax declarations (between the most recent tax declaration and the application for the licence), the following documents have to be attached: a copy of your pay slips for that period*; an overview of your income from movable property and capital (this includes dividends, interests, income from rent, leasing, use and concession of movable property and income included in annuities or temporary interests, excluding pensions); if you have sold real estate in that period, a copy of the deed of sale has to be attached. (*) Self-employed people have to give an overview of their profits for that period.

2 2) Loans If you have taken out one or more loans (with or without mortgage), please complete the following table: Name + address of the institution Start date Duration Amount Type of the mortgaged asset + amount 3) Security Have you, your spouse or one of the persons for whom you are financially responsible taken out a security? If so, please complete the following table: Beneficiary (name, first name, address) Amount Name + address of the institution Date of opening of the account Type of the account 4) Foreign accounts Have you opened a foreign account with a bank or an exchange, credit or savings institution based abroad? If so, please complete the following table: 5) Bankruptcy If you have been connected with a company that has been declared bankrupt during the period you were part of it, please complete the following table:

3 Name + address of the company Date of the declaration of bankruptcy Position of the applicant in the company (employee, executive, shareholder)

4 B. LEGAL PERSONS I. IDENTIFICATION Company number:... Licence number:... Legal name:... Address of the head office: Street:... No:... Box:... Postal code:... Municipality:.. Country:... Phone:... address:... Commercial name of the website:... Data concerning the executive(s) or director(s) Name:... First names: Date of birth:... Place of birth:... Nationality:... National registry number:... Street:... No:... Box:.. Postal code:... Municipality:... Name:... First names:... Date of birth:... Place of birth:... Nationality:... National registry number:... Street:... No: Box:... Postal code:... Municipality:... Name:... First names:... Date of birth:... Place of birth: Nationality:... National registry number:... Street:... No:... Box: Postal code:... Municipality:...

5 II. JUDICIAL PAST OF THE EXECUTIVES AND DIRECTORS Pursuant to the legal provisions, the Gaming Commission will verify whether you fulfil the moral requirements in the Central Judicial Record, whether you are registered in the municipal register and whether you possess full political and civil rights. III. FINANCIAL SITUATION Please attach the declarations of company tax with the corresponding documents, statements and information of the past three tax years. C. INFORMATION CONCERNING NATURAL AND LEGAL PERSONS C. 1. DATA CONCERNING THE GAMES OF CHANCE OFFERED Please indicate below which games of chance you wish to offer. C. 2. DOCUMENTS TO BE ATTACHED Please attach the following documents: an advice issued by the Federal Public Service Finance which proves that the applicant has fulfilled all their fixed and uncontested tax debts; a list of the type or variety of games of chance offered; a piece proving your solvency and financial resources, in particular the proof that you possess sufficient financial means to pay the security for the amount of 10, euro; the rules of the games of chance; the establishment in which the server is located and the identification of the server(s) on which the data and the website are managed; the name of the website. Remarks: 1) If the space provided is not sufficient to give a complete answer to the questions, please indicate this clearly and refer to the attachment in which you have completed your answers. 2) Any changes during the processing of the application have to be communicated to the Commission as soon as possible. The accuracy of the data has to be guaranteed. 3) Any change after the issuing of the licence has to be communicated to the Commission as soon as possible. 4) Any deliberate communication of incorrect information results in the refusal of the licence.

6 5) If the applicant is a citizen of a member state of the European Union or a legal person pursuant to the law of a member state of the European Union, they have to attach equivalent foreign documents concerning the financial, fiscal and judicial situation to the application of the licence. At the simple request of the Commission, the applicant provides the Commission with a translation of those foreign documents into one of the three Belgian national languages. Date:... Signature:...

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